Exerscience Intake Form

Exerscience Intake Form
Patient Information
Upload Your State Drivers License (if minor, upload Guardians Identification)*
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Gender
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Emergency Contact Person*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Medical Doctor's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Hospital Name
How did you hear about us?*

Referred by physicianWalk-InInternet SearchNeighborhood NewsSocial MediaFriend/family/current patient (please type their name in other)
Medical Data
Purpose of visit or complaint*
Did the pain start after a specific date or develop over time?*
When did you start experiencing this problem?*

MonthDayYear
Date
Have you had any of the following imaging?

MRICat ScanX-raysEMGother
Upload any imaging or records pertaining to your visit.

Browse Files

Cancelof
Health Condition*

HypertensionHeart issuesRashesDiabetes MellitusBone problemsBleeding disorderSpams/CrampsSprainsVaricose VeinsConstipationArthritisSpinal Cord IssuesChronic coughAsthmaNeck painBack painHips painLegs painInfectious diseasesVision problemKidney disorderHeadachesDizzyFainting SpellsStrokePregnancyEmphysemaPacemakerOther respiratoryTBSeizureCancerHepatitis A,B, or CEpilepsy
Height and Weight *
Are you pregnant, breastfeed, or nursing? (Female)*

YesNo
Are you smoking? If yes, how many packs a day?
Do you exercise daily?*

YesNo
What type of exercises you do?

StrenuousModerateLightNone
Are you wearing any implantable medical devices? If yes, what are these devices?*
Are you currently taking any medications? If yes, please list them below:
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
Have you experience any pain in any part of your body? If yes, please indicate what body part. Please be specific.

In scale of 1-10, how much pain are you feeling RIGHT NOW? *

	0	1	2	3	4	5	6	7	8	9	10

0 is No Pain, 10 is Worst Pain

In scale of 1-10, how much pain are you in AT YOUR BEST MOMENTS.

	0	1	2	3	4	5	6	7	8	9	10

0 is No Pain, 10 is Worst Pain

What relieves your pain?

In scale of 1-10, how much pain are you feeling AT YOUR WORST MOMENTS?

	0	1	2	3	4	5	6	7	8	9	10

0 is No Pain, 10 is Worst Pain

What increases your pain?
What type of pain are you experiencing?

NumbnessSharp painTinglingBurningDull painStiffness
Is your pain

IntermittentConstantWith specific motionsWaking you at night
Annotate Image
As it relates to your current problem, are you unable to or have difficulty with performing any of the following activities? Do you have pain associated with or have you changed your method of performing any of the following tasks? Check all that apply.

Getting in and out of bedGetting in and out of a carGetting in and out of a chairBathing/ShowingCookingCleaningShoppingLiftingWalkingAscending/descending stairsSittingStandingRunningJumpingSleepingEatingShavingDressingShavingWork ActivitiesDrivingOther
Have you have family history of the following medical diagnosis?

Cardiovascular diseaseDiabeter MellitusCancerAsthmaArthritis
Authorization and Consent

Financial Policy

NEUBIE Waiver

Optional Treatment Consent Form
Consent to Neubie Treatment*

Dry Needling Waiver

Optional Treatment Consent Form
Consent for Dry Needling*
Patient's Signature (Guardian if under 18 years of age)

Clear

Communication Policy
Communication Preference*
I grant permission for The ExerScience Center to speak with the following individuals concerning myself and my treatment plan...

HIPPA Privacy Practices
I have had full opportunity to read and consider the contents of this Acknowledgment and the Notice of Privacy Practices. I understand that, by signing this Acknowledgment, I am giving my authorization to your use and disclosure of my protected health information.*

Clear
I hereby authorize and direct The ExerScience Center as well as their associated providers, employees, office staff, and agents including affiliated health care practitioners (collectively "The ExerScience Center") to use and disclose my "protected health information" ("Information"), as described below.

Description of Information. I understand that my Information includes, but is not limited to, my name, date of birth, and other personal information and identifiers (including my address), medical information, including information about my health condition and related medical conditions, medical records, and financial information (including information about my insurance) as well as other personal information collected by The ExerScience Center about me or otherwise provided by me to The ExerScience Center.

Purposes. I authorize and direct The ExerScience Center to use my Information, and to disclose my Information for the following purposes: For marketing communications. For example - The ExerScience Center may contact me about new products, services, or events that it thinks may be of interest to me. The ExerScience Center may also contact me for the purposes of fundraising, publicity and advertising for broadcast in print or other media including on the internet. Note that The ExerScience Center may receive remuneration, either directly or indirectly, in exchange for making these marketing communications. For purposes related to treatment, payment (e.g., to a parent, other family member or personal representative who may assist in coordination of my care) and/or The ExerScience Center health care operations, with the following individuals:
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number

Testimonial and Photo Release
I understand my testimony may be used in connection with publicizing and promoting The ExerScience Center. I authorize The ExerScience Center to use my name, photograph, brief biographical information, and testimonial.

I grant The ExerScience Center, its representatives and employees the right to use myname, photograph, brief biographical information, and testimonial in various marketinginitiatives. I understand that this information may be used in various mediums for suchpurposes as publicity, illustration, advertising and Web content. I authorize TheExerScience Center to copyright, use and publish these materials in both print andelectronic formats for purposes of publicizing The ExerScience Center.

In addition, I waive any right to inspect or approve the finished product wherein mylikeness or my testimony appears. I agree that I will make no monetary or other claimsagainst The ExerScience Center for the use of my name, photograph, brief biographical information, and testimonial.

I hereby RELEASE, WAIVE and FOREVER DISCHARGE any and all claims arising out of, or in connection with, such use The ExerScience Center, including without limitation any and all claims for libel or invasion of privacy.
I hereby warrant and represent that I am at least 18 years of age and have the right to contract in my own name. I have read the above Release and am fully familiar with the contents thereof. This Release contains the entire agreement between the parties hereto as to the subject matter contained herein. I have read, understand and agree to the above.
*

Yes, I agree with terms.No, I do not agree.

No Show/Cancellation Policy

Policies, Rules, Session Etiquette

Signature of Confirmation
I have read and completely understand these terms. If I have any questions regarding this form, I will ask before signing.

Clear
Should be Empty:

Exerscience Intake Form

Patient Information

Medical Data

Authorization and Consent

Financial Policy

NEUBIE Waiver

Dry Needling Waiver

Communication Policy

HIPPA Privacy Practices

Testimonial and Photo Release

No Show/Cancellation Policy

Policies, Rules, Session Etiquette